The present disclosure relates generally to surgical devices and more particularly to a device and methods for lifting tissue of a patient prior to insertion of a surgical instrument such as a trocar or Veress needle.
During various surgical procedures, including laparoscopy, surgical instruments such as a trocar, Veress needle or access port may be inserted into the tissue of a human or animal. In some procedures, the instrument is inserted in a position to access the abdominal cavity. The initial surgical instrument or trocar is preferably placed through the umbilicus because the abdominal wall is at its thinnest in this region. A laparoscopic camera is then placed through this initial trocar to aid in visualizing the intraabdominal cavity and the structures therein. Carbon dioxide gas is then used to insufflate the abdominal cavity, thereby creating a pneumoperitoneum or space to operate. Once the pneumoperitoneum is created, secondary trocars can be placed under direct visualization utilizing the laparoscopic camera thus reducing the risk of injury.
Patient injuries most often occur during initial placement of the trocar or Veress needle, which is generally considered to be the most dangerous portion of a laparoscopic surgery. Currently, there are two common methods for the placement of the primary umbilical trocar: the blind technique and the open (Hasson) technique.
The blind technique can be accomplished either before or after the creation of the pneumoperitoneum. Some surgeons prefer insufflating the abdominal cavity prior to the placement of the initial trocar. This is accomplished with the use of a Veress needle. The needle is blindly introduced through an umbilical incision. Carbon dioxide gas is introduced through the Veress needle, elevating the abdominal wall away from the underlying structures. The Veress needle is then removed, and the primary trocar placed.
Other surgeons prefer placing the primary trocar prior to insufflating the abdomen. This is the direct entry method and is performed using a technique called a “controlled jab.” The trocar is placed through an umbilical incision under controlled force using a stabbing motion with care not to penetrate beyond the abdominal wall. Most surgeons elevate the abdominal wall during blind insertion of either the primary trocar or the Veress needle. This reduces the risk of injury to underlying structures.
The most common type of injury is to vascular structures, bowel, or to other visceral organs. Multiple studies have shown that complication rates are similar between the Veress needle and direct entry as well as between the blind technique and the open Hasson technique. Various techniques and inventions have been described to assist with elevation of the abdominal wall to facilitate blind trocar or Veress needle placement. This includes rarely used devices such as retractors and lifting rods used to mechanically elevate the abdominal wall thereby creating negative pressure within the abdomen allowing a space for initial trocar placement or room to operate without the need for creating a pneumoperitoneum.
More commonly, two conventional manual techniques for lifting the abdominal wall are utilized. The first method involves grasping and lifting the abdominal wall below or on either side of the umbilicus with one's hand. The second method utilizes perforating towel clips placed in a similar location to provide a handle on which to lift and elevate the abdominal wall. Each of these techniques require that sufficient elevation of the abdominal wall is maintained in opposition to the downward force generated during primary trocar or Veress needle placement. Although providing a more secure grasp of the abdominal wall, towel clips pierce the abdominal skin and therefore risk injury and trauma to vessels and tissue. This is also a source of postoperative discomfort to what is intended to be a minimally invasive procedure. Grasping and lifting the abdominal wall by hand poses its own challenges. Whether the surgeon is lifting the abdomen below the umbilicus or the surgeon and his assistant are lifting on either side of the umbilicus, it can be difficult to maintain a grip and the proper elevation to insure inadvertent injury does not occur to the underlying structures. The shape, elasticity and overall thickness of the abdominal wall can also prohibit one from adequately grasping the abdomen by hand. Also, lifting the full thickness of the abdominal wall by hand risks inadvertently grasping and elevating the omentum and other underlying structures together with the abdominal wall bringing these structures into the path of the trocar or Veress needle.
In an effort to improve on current tools and techniques, a number of devices have been developed. One recent apparatus, marketed under the name of LapDome by Narbitas, utilizes a dome shaped device and negative pressure generated from external operating room suction to raise the abdominal wall within the dome thereby creating intraabdominal space. A Veress needle is then introduced through the dome and into the elevated abdominal cavity. The abdominal cavity is then insufflated with carbon dioxide gas, and the surgery can commence as usual.
There are several drawbacks to using the LapDome and similar devices. First, it is a bulky apparatus fixated over the abdomen and umbilicus and requires external suction to create lift within the device. Second, the LapDome can be used only with the Veress needle technique and therefore limits a surgeon to a technique that he or she may not be comfortable with performing.
What is needed then are improvements to devices and methods for laparoscopic surgery, and particularly for manipulating and lifting patient tissue for insertion and placement of a surgical device during a surgical procedure, such as but not limited to a trocar or Veress needle.